Catarina Lundberg

DEMENTIA AND DRIVING: AN ATTEMPT AT CONSENSUS

Summary:The number of older drivers in Sweden will be rapidly increasing during the next decades. A possible relationship exists between the increased relative crash risk of older drivers and the prevalence of age-related diseases such as dementia. However, a clear-cut policy for evaluating driving competence in demented persons is still lacking. In recognition of this fact, the Swedish National Road Administration invited a group of researchers to formulate a consensus on the issue of driving and dementia. This consensus document is aimed at providing primary care physicians with practical advice concerning the assessment of cognitive status in relation to driving. Suggestions are based on a review of existing research and discuss the use of general and driving-specific sources of information available to the physician. Consensus was reached on the statement that a diagnosis of moderate to severe dementia precludes driving and that certain individuals with mild dementia should be considered for a specialized assessment of their driving competence.

The 1994 International Consensus Conference on Dementia and Driving: a brief report. Swedish National Road Administration.

A possible relationship exists between the increased relative crash risk of older drivers and the prevalence of age-related diseases such as dementia. However, although dementia affects cognitive functions essential for safe driving, the evaluation of driving competence in demented persons is problematic. A clear-cut policy, intended chiefly for primary care physicians, is still lacking. In recognition of this fact, the Swedish National Road Administration invited a group of researchers to review existing research and to formulate a consensus on the issue of driving and dementia. The consensus group suggested that physicians should routinely make a cursory evaluation of the mental condition of their older driving patients. When signs of cognitive impairment are detected, possible influence on visuospatial skills, attention, judgment, and memory functions should be carefully considered. Information from caregivers on past and current driving performance as well as functions relating to activities of daily living (ADL) should be taken into account. Consensus was reached that a diagnosis of moderate to severe dementia indicates sufficient cognitive impairment to preclude driving. In addition, diagnosed mildly demented individuals or nondiagnosed cognitively impaired individuals with functional deterioration should be considered for specialized assessment of driving competence.

The Nordic Stroke Driver Screening Assessment as predictor for the outcome of an on-road test

The use of the cognitive test battery Nordic Stroke Driver Screening Assessment (NorSDSA) has increased, sometimes as a stand-alone test to evaluate fitness to drive, also for non-stroke patients such as patients suffering from cognitive deficits/dementia, approaches that may be questioned. The objective of the study was to determine whether the NorSDSA could predict an on-road test result, for large sets of stroke (n=74) and cognitive deficits/dementia participants (n=116), respectively. The percentage of correctly classified was 62% for the stroke group and 50% for the cognitive deficits/dementia group. A discriminant analysis with pass/fail on the on-road test as grouping variable could classify 62% of the stroke participants and the cognitive deficit/dementia participants. Hence, the NorSDSA could not predict the outcome of the on-road test. Therefore, NorSDSA should not be used as a stand-alone test to determine the fitness to drive of individual participants. Also, its use with participants suffering from cognitive deficits/dementia appears to be less successful than for clients with stroke.

Assessment of driving after stroke—A pluridisciplinary task

UNLABELLED The aim of the study was to analyze the assessment procedure and identify predictors for the team decision when assessing fitness to drive a car after stroke. The material used was a retrospective data set with 200 stroke clients from Queen Elisabeths Foundation Mobility Centre at Banstead UK. Fifty-four percent of clients were considered fit to continue driving where 9% could resume driving after car adaptation and training. Important factors for the outcome were vision (acuity and field), neuropsychological functions (divided attention), and track and/or on road test (reaction time, anticipation, speed, and positioning). Cognitive impairment was the main problem in those who failed the driving test and judged not fit for continued driving. Car adaptation, mainly comprising infrared transmitted secondary controls together with automatic transmission was recommended in 35% of the cases. CONCLUSIONS The contribution of different specialist groups appears to be necessary for an effective evaluation, but the assessment procedure can be done more cost-effectively by dividing it into two separate parts and removing certain subtests. The in-car track test is an important part of the assessment procedure with a high face validity and could in many cases make it unnecessary to perform in-traffic tests with unsafe drivers. Car adaptation is often necessary for a client with pronounced hemi-paresis and a full road test can for those only be performed after training the use of car controls.

A Swedish survey of occupational therapists’ involvement and performance in driving assessments

The purpose of this study was to examine the extent to which occupational therapists (OTs) are involved in driving assessments in Sweden and how these assessments are performed. A questionnaire was sent to 154 geriatric, rehabilitation, and neurological clinics, and additionally directly to 19 OTs who had purchased a test battery specifically used for driving assessments. The response rate was 60%. Of those responding, 57% reported being involved in fitness-to-drive assessments. However, such assessments were carried out in various manners and diverse methods were used, ranging from unstandardized activity assessments to a test developed specifically for driving assessments. Only 19% used on-road driving tests as a complement to the clinical assessments. Apart from the lack of appropriate methods, the respondents said that they did not have sufficient knowledge to perform driving assessments and expressed a need for further education. In the future it seems necessary for OTs in Sweden to undergo specialized training and perform the assessments on a regular basis to maintain a high level of competence as driving assessors.

Health-adjusted neuropsychological test norms based on 463 older Swedish car drivers.

There is a need for improved normative information in particular for older persons. The present study provides neuropsychological test norms on seven cognitive tests used in a sample representing the general older driving population, when uncontrolled and controlled for physical health. A group of 463 healthy Swedish car drivers, aged 65 to 84 years, participated in a medical and neuropsychological examination. The latter included tests of visual scanning, mental shifting, visual spatial function, memory, reaction time, selective attention, and simultaneous capacity. Hierarchical regression analyses demonstrated that, when uncontrolled for health, old age was associated with significant impairment on all seven tests. Education was associated with a significant advantage for all tests except most reaction time subtests. Women outperformed men on selective attention. Controlling for health did not consistently change the associations with education, but generally weakened those with age, indicating rises in normative scores of up to 0.36 SD (residual). In terms of variance explained, impaired health predicted on average 2.5%, age 2.9%, education 2.1% and gender 0.1%. It was concluded (1) that individual regression-based predictions of expected values have the advantage of allowing control for the impact of health on normative scores in addition to the adjustment for various demographic and performance-related variables and (2) that health-adjusted norms have the potential to classify functional status more accurately, to the extent that these norms diverge from norms uncontrolled for physical health.

The Nordic Stroke Driver Screening Assessment as predictor for the outcome of an on-road testThe Nordic Stroke Driver Screening Assessment as predictor for the outcome of an on-road test

The use of the cognitive test battery Nordic Stroke Driver Screening Assessment (NorSDSA) has increased, sometimes as a stand-alone test to evaluate fitness to drive, also for non-stroke patients such as patients suffering from cognitive deficits/dementia, approaches that may be questioned. The objective of the study was to determine whether the NorSDSA could predict an on-road test result, for large sets of stroke (n=74) and cognitive deficits/dementia participants (n=116), respectively. The percentage of correctly classified was 62% for the stroke group and 50% for the cognitive deficits/dementia group. A discriminant analysis with pass/fail on the on-road test as grouping variable could classify 62% of the stroke participants and the cognitive deficit/dementia participants. Hence, the NorSDSA could not predict the outcome of the on-road test. Therefore, NorSDSA should not be used as a stand-alone test to determine the fitness to drive of individual participants. Also, its use with participants suffering from cognitive deficits/dementia appears to be less successful than for clients with stroke.

Five-year change scores in old age for six neuropsychological tests and normative data for the Useful Field of View (UFOV) test: The influence of physical health

ABSTRACT Introduction: Neuropsychological assessment of cognitive change over time is often conducted in clinical settings, but whether neuropsychological change scores are influenced by physical health has, as far as we know, not been examined previously. Method: In a sample of 153 older Swedish adults (age range, 72–86 years), we evaluated the influence of common age-related diseases, terminal decline pathology, age, education, and gender, to provide (a) preliminary test-specific regression weights and 90% confidence intervals to assess significant change in performance after five years on tests of visual scanning, mental shifting, visual spatial ability, memory, reaction time, and selective attention, and (b) normative data for the Useful Field of View test (UFOV) from a single testing occasion. Results: Multiple regression analyses showed that test–retest changes were affected by physical health for mental shifting, visual spatial ability, memory, and reaction time, by age for mental shifting and visual reaction time, by education for visual spatial ability, and by Age × Education for auditory reaction time. Gender did not affect any of the change scores. The overall average of variance explained was 2.5%: up to 8.1% for physical health, 4.4% for age, and 3.6% for education. The UFOV scores were mostly influenced by age, but also by physical health and education. Conclusions: The findings indicate that considering the influence of health on normative change scores in old age in addition to demographic factors leads to more accurate predictions of whether true change has occurred.

Driving and dementia: What factors influence how physicians address the issue? Data from the Swedish Dementia Registry (SveDem)

INTRODUCTION: In Sweden, physicians are required to report dementia patients who are unfit to drive to the Swedish Transport Agency (STA). However, physicians may refrain from reporting if there is reason to believe that the patient will cease to drive as part of an agreement. Aims: To investigate to what extent physicians address driving and dementia, and whether there is a difference in how the issue is addressed depending on patient-related factors. Material and Methods: Data on 13852 newly diagnosed dementia patients, who held a drivers license, was obtained from the Swedish Dementia Registry. Associations between patient-related factors and being reported, or an agreement being reached, were examined in binary logistic regression. RESULTS: Physicians had not taken any action in 17% of cases. Male gender (OR 2.97, pCONCLUSIONS: Physicians, collectively, omit to address the issue of diving and dementia in almost 20% of dementia patients, and are thus noncompliant with national law and regulations. Furthermore, a difference in practice was observed in patients with DLB and FTD, but more evidence is needed in order to determine what the practical implications are. 0 Language: en

Assessment of Fitness to Drive, Possession of Professional Drivers’ License, Possession of Firearms, and Pilot’s Certificate in Clients with Dementing Conditions

There is a high degree of likelihood that impaired cognitive functions affect traffic safety and traffic behaviour. The risk of crash involvement may increase due to the cognitively impaired driver’s own mistakes or his/her diminished ability to parry the mistakes of other road users. Therefore, it is important, when assessing memory impairment or dementia, also to consider the issue of automobile driving, operating trains or aircraft etc. The ability to take in and correctly process visual input is also an important ability for hunters, which raises the issue of the possession and use of firearms. Psychotic symptoms in a demented person entail a clear risk of shooting at imaginary pursuers, or a depressed person may use the firearm to commit suicide. Impaired cognitive functions do not increase the crash risk only of drivers of automobiles, trains and aircraft, but, probably also for drivers of mopeds and bicycles. Increased instability when riding a bicycle is not seldom reported by patients at our memory clinic (KJ, personal experience), but has not been systematically investigated.